Healthcare Provider Details

I. General information

NPI: 1275549313
Provider Name (Legal Business Name): SUSAN P ANDERSON D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5412 BRIDGE ST SUITE A
ROSCOE IL
61073-8571
US

IV. Provider business mailing address

5412 BRIDGE ST SUITE A
ROSCOE IL
61073-8571
US

V. Phone/Fax

Practice location:
  • Phone: 815-623-1900
  • Fax: 815-623-1933
Mailing address:
  • Phone: 815-623-1900
  • Fax: 815-623-1933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number19024372
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: